Thursday, August 30, 2007

Man, I love the Rocky Mountains. I'm spending the end of my week off up here with my mom & stepdad, eating my leftover wedding cake and thoroughly relaxing. I took a walk around a mountain lake today (huffing and puffing--I don't do well with altitude). It felt great to be outside in the middle of the day and NOT be covered in sweat. Tonight, I'm sleeping in full PJ's and a sweatshirt, because it's getting down to the 40's tonight--such a wonderful change from our 85+ degree apartment (and we STILL have $200 electric bills!). Also, I learned something very interesting: my mother has started writing fan fic.

My mother.

Writes fan fic.

About her favorite television show, Jericho, which was canceled.

Life never stops being weird, does it? I outed myself as a blog writer and she kind of went, "That's nice." I guess some things never change. (You don't read this, but I kid, Mom, I kid!)

Actually, some things do change. My mom has lost 20+ lbs and LOVES it. My sister has lost around that amount, and my dad has lost 25 lbs. That leaves me, The Last Fatass. It's so easy to say "It's too hard in medicine, I don't have time to eat right, I don't have time to exercise," but that scares me, because my life is never going to be stress-free. It's never going to be any easier to exercise, or eat well, or take better care of my plants and pets. I keep saying this, and I keep sitting on my butt watching Discovery Channel instead of going to the gym. I also keep saying, I don't care how much I weigh, so long as I am fit, but it's a lie. I want to be thin, or at least thinner. I'm tired of being barely under the "obese" category of BMI. For now, though, I'd settle for being able to climb a flight of stairs while having a conversation, or two flights of stairs without being winded for 10 minutes afterward.

Friday, August 24, 2007

So my four weeks at [Other School] are over, and I have a week off before starting up on inpatient child psych. I'm ready for a break, at this point, but part of me is already missing my rotation. I liked my residents, I liked the other med students on the team, and I liked my attending, who kind of reminded me of my mother in some ways. I took some calls in the Psych Emergency Center, which were always entertaining, if a little bit shockingly cynical at times (a story for a different day, perhaps). At the end of the rotation, I'd earned a letter of recommendation from my attending, help with my personal statement from one resident, and the other resident's "blessing" should I ever want to attend their residency program. Since I felt like a huge goober much of the time, it was really nice to know I hadn't blown it all month.

I learned how much I like personality disorders this month. Patients with borderline or narcissistic personality are extremely difficult to work with by nature of their disorders, but I find them fascinating. We interviewed a young woman who had injured herself during a fight with her boyfriend; she'd not intended to really harm herself, but had to come to the hospital. Her story involved years of depression and suicidal thoughts, repeated cutting and burning of her skin, anxiety and panic attacks. No, she'd never suffered any real trauma, she said; a few minutes later, she calmly mentioned childhood abuse which had landed her in foster care through high school. She was totally detached from the abuse and made no connection between it and her violent mood swings or her need to cut her skin to release anger. It's easy to see the scary borderline patient, fear their manipulation and lies; it's more meaningful for me to learn their story. This girl was classic borderline, but she's young enough and willing to seek help that I have hope she may improve.

I learned I can control my emotions better this month. Even when I feel myself tearing up while a patient cries, or reveals a tragic history, I can hold it back. I feel the emotion, I acknowledge it, but I'm able to avoid crying with the patient. This was something I was really afraid of when I entered medicine, so I'm rather proud that I can do this.

I went to a talk on perfectionism in physicians during this rotation. It was like watching my most private thoughts and feelings be displayed in front of a room of people. Most people hear "perfectionism" and think high performance or success; one website I Googled said "The root of excellence is perfectionism." In psychological terms, though, it's a never-ending drive for an unachievable goal, which leads to constant low self-esteem and failure. One thing mentioned which I didn't realize was common was the feeling of fraudulence: it's common to feel that one is a fake, that everyone has been fooled so far into thinking one is smart, and only one small misstep will reveal the real, stupid self. This kind of compulsive, negative thinking and behavior can contribute to burn out, depression, substance abuse, and suicide; this frightens me, as I've already experienced the first two.

I realized I enjoy psychiatry passionately. There are things I hate as well as things I love, but fortunately more of the latter. This decision feels so right, and yet it is SO HARD to explain in my pitiful little personal statement, which has been revised by at least 5 people and is still inadequate. I'm going to be a very stressed out TS until March 2008 when the Match results are published. Until then, it's one deadline after another, CV's going everywhere, applications on various websites, money money money, checking on letters of recommendation, scheduling interviews, ranking programs... It's a wonder any of us get through all this!

Tonight, though, I watched a healthy dose of "What Not to Wear", cleaned my kitchen, cared for post-neuter kitty (he's doing well), and will now go to bed, because I love to sleep. Man, do I love sleep.

Friday, August 17, 2007

Whoever made these videos was BRILLIANT. Taking my favorite commercials ever--"Real Men of Genius"--and applying them to medical students--"Real Med Students of Genius"--makes my inner nerd very, very happy. It's a good thing I wasn't drinking anything while I was watching these, because I've already aspirated and spat out zero-calorie soda once today, which is one time too many.

Many thanks to: The University of Maryland School of Medicine, Class of 2006 for taking time out of their busy fourth year schedules of lounging around, avoiding scut, and generally not working long enough to create these fantastic videos.

In case you wanted to read a careful analysis of the recent Partial-Birth Abortion Ban decision from the Supreme Court, I suggest you go here. I won't try to recreate it, but let me just say I agree with his assessment, and I'm ashamed that I didn't try to do as much reading on the subject myself, as it is something I feel strongly about.

What I'm asking for is this: if just ONE person (of the 3 who read this) could think about why they come over to this corner of the internets to read this thing, write it down (just a sentence or two), and post it in the comments section of this post, that would be AWESOME.

Saturday, August 11, 2007

I was reading the "America's Best Hospitals 2007" feature in US News & World Report recently, and one article in particular caught my attention. The article addressed bacterial contamination in the hospital; apparently, even though restaurants and cruise ships are routinely checked for germs, hospitals are NOT. No one routinely checks the amount of MRSA on the floor or operating table in the OR; no one swabs the ventilator machines in the ICU for VRE; no one looks to see which surfaces are contaminated with resistant Acinetobacter. This in itself is rather shocking to me; if we check the place which packages our hamburger meat, how can we not check the place where we allow our bodies to be cut open?

The most shocking point of the article, though, was the accusation that doctors' white coats are a source of infection. I fall into the 16% of doctors in one survey who admitted not washing their white coats in over a month. While they don't present actual data, the most recent article I found (BMJ, 1991) showed Staph aureus contamination on the pockets and cuffs of over 25% of doctors' coats. They recommended washing coats once a week and removing them when checking surgical wounds.

It's rather shocking that the most recent article I found on Pubmed was done in 1991. Similarly, articles on stethoscope contamination are hard to come by, but seem to suggest that frequent wiping with alcohol, at least once a day, can prevent transference of bacteria within the hospital.

This leaves me with a few questions:

Why aren't more studies being done in these areas? Is there a lack of funding, or a lack of interest? Are we afraid to see just how often WE cause the infections?

Why isn't this data more widely known? Signs about hand-washing blare on every wall of the hospital. I've never seen a sign that said "Wash your coat!" or "Take this alcohol wipe and use it on your stethoscope!"

Why do we wear the white coat?

So, why do we wear the white coat? Sure, it differentiates doctors from non-doctors (generally), and the short coat differentiates the medical student, but is this all? I mean, I stuff the pockets with books, H&P paper, pens, PDA, etc., but pockets in pants or a sweater would do as well. Alternately, we could all wear fanny packs, which the anesthesiologists are keeping in style, or carry back packs or purses. There are other ways to tote what we need--so why the coat?

Is it the tradition? Just like medical rounds, or the tradition of medical hierarchy, or "residency", or pimping, any of the other crap we do just because it's always been done that way. Is it because wearing a white coat makes us feel special, important, and causes people to call us "Doctor"? A well-displayed name badge can do the same thing.

Reading that article just really got me to thinking. It's difficult to unload my white coat, use the bleach pen on the pen marks, wash it, dry it, and reload it. Or is it? Am I just lazy? (Yes!) Would it be better, for purposes of infection control, to have a laundry service for lab coats? Some hospitals have such a thing, but even then doctors often don't utilize it (I've watched my residents). If this is such a problem, wouldn't it be in the hospitals' best interest to require a coat exchange or laundry service?

It's interesting that the hospitals are so scared of JCAHO finding an order that isn't dated, timed, signed, stamped, with a pager and dictation number on it, but no one's checking up on the VRE which may be on the EKG wires or the C. difficile on the blood pressure cuffs (EWWWWW--just remember this is fecal-oral!). I doubt these incidents are unique to the hospitals mentioned in the article. I'd imagine that if all hospitals were routinely swabbed and cultured like we do our patients, we'd find sources of these "super bugs" in unusual places, places we don't usually think to check. Apparently, though, JCAHO only bothers to investigate a "visibly dirty" room, but does not routinely check bacterial contamination on its hospital accreditation inspections.

For example, a friend of mine went to school in the Northeast, where computer kiosks were located throughout the campus. Between classes, students would be found at these computers messaging each other. One day, a few students present to the student health clinic with pink eye. It's only a couple of cases, and the most common cause of pink eye is viral, so the doctors tell the students not to worry, just use some eye drops, avoid touching their eyes and wash their hands frequently, as it's quite contagious. Only more and more students start to come to the health center with pink eye. The first to be infected aren't getting better, either, as you'd expect with a viral conjunctivitis. Finally, someone requests antibiotics, takes them, and recovers; finally everyone realizes the infection is bacterial, the affected students are treated, and the incident resolves.

So how did a large percentage (14%) of this campus contract bacterial conjunctivitis? It turns out that the infection had found a nice place to reside: the keyboards of these computer kiosks. In addition to other means of infection control (hand-washing, etc.), they replaced the keyboards, as they're difficult to disinfect.

How many patients have I touched after using the computer to look up labs? I really try to use the alcohol gel before and after I see patients, but I forget. How about the phones? The doorknobs?

Here's why we don't routinely culture hospitals, even though we used to until 1970: Yet the CDC's latest guidelines still deem routine testing for bacteria unnecessary. "If you culture on a regular basis, you're always going to find something," says Denise Cardo, who runs the CDC's division of healthcare quality promotion. "You don't want the labs to be used for that instead of tests on patients."

If you culture on a regular basis, you're going to find something? I realize cultures can be contaminated themselves, and they're not perfect, but my god, the reason you find something is perhaps because there's something to find! Sure, we assume that the floor is dirty, but who thinks about touching a telephone? Or our personal cellphone? Our pager or our pen?

Fortunately, the article suggests a simple solution: more soap and water. The British National Health Service tried doubling the hours of the cleaning staff on one ward, and reduced MRSA infections by 90%. The cost reduction from having fewer infections paid for the janitorial staff increase many times over. An article in the current Journal of Hospital Infections (July 2007) describes simple modifications in cleaning technique which reduced "residual organic soil"--bacteria breeding ground--from 86-100% after cleaning to 0-14% after cleaning.

In other words, we know what we have to do. What is keeping us from doing it?

Friday, August 10, 2007

Consult-Liaison is kind of fun. It's a lot of work, but I like being the integrative force for a patient. So often, 5 or 6 different teams of 8-9 people each are coming by to see a patient on any given day, each with their own plans for the patient. What ends up happening is that the overall plan will be lost on the patient, who is confused and feeling alone. When we are consulted, I take the time to read the chart and know all the plans (as best I can) in order to a) determine how it impacts OUR plan and b) know what to say to the patient in case they ask me what's going on.

I like the lifestyle. I really don't care what the money is going to be like (the average doctor is making a decent living, regardless of specialty), but I like knowing that I can be flexible in my schedule. It's important to me that my family know me, and I think I have a better chance of making a good schedule on psych.

I like the discussions. They don't feel as inhumane as the endless differential diagnosis conversations in internal medicine, in part because we consider the whole person. We talk about their medical problems, their psych problems, social issues, substance abuse, and anything else that seems applicable.

I like the people. They're not as malignant and gossippy as some of the OB/Gyn's I worked with; they're not as snotty and self-loving as the surgeons; they're not as full of their own intelligence as the internists; they have better senses of humor than the pediatricians; and they don't have inferiority complexes as large as the family docs. Obviously, these are generalizations, and I'm sure there are psychiatrists I will not like. Overall, though, I get along with the psychiatrists, and that's important to me.

I like that the field is evolving so rapidly. I'm sure many of our current diagnoses will be totally re-written within 20 or 30 years as we understand more about the brain and the genetics of disease. By the end of my career, I'm sure much of what we do now will be seen as primitive and misguided, and that's fine with me. As long as we do our best and treat patients with kindness and current knowledge, we'll ride the waves.

Basically, I'm a little confused (and ashamed) that I put off not liking psych. I thought of it as not being real medicine, as being too soft, as "beneath me" if I may put it that way. I'll confess to not being entirely past those thoughts; part of me feels regret for all the other parts of medicine I'll leave behind. I can't have it all, though, and I rejected those other parts of medicine for good reasons. I just have to remind myself of them from time to time.

Feels good to be home for the weekend. While sitting here earlier, I was surprised by a knock on the door. When I answered it, two of my friends were standing there, with a stack of plates of fresh chocolate chip cookies that they were passing out to their friends. It was about the sweetest thing I've experienced in a while.

Thursday, August 09, 2007

I always like it when people make insightful criticisms of the way we currently practice medicine, especially when they make actual suggestions for improving things. If you appreciate this too, please check out this post over at Over!My!Med!Body!. He makes some fascinating suggestions for improving the age-old tradition that we call "rounding". He actually suggests that rounding may not be the most efficient way to take care of patients--blasphemy! I love it as much as I hate rounding!

Tuesday, August 07, 2007

1) Obviously, I moved the blog. Thanks for coming! In the end, I couldn't think of anything more creative than "Tiny Shrink", which is kind of redundant, if you think about it.

2) It came to my attention that someone tried to reach me via the email address I'd set up just for the blog, and I hadn't checked it in months, and so I missed their email, and was a jerk. I've created yet another email address for THIS incarnation of the blog, and I've set it up to forward to my main email, so this should never happen again. Lo siento mucho. I may still be a jerk, however.

3) I'm currently on an away rotation, which I got switched from urology to psychiatry at the last possible minute. I'm in a different city for 4 weeks, at a program I like, doing consult-liaison work at a large public hospital. I was informed by a resident today that they do not like blogging about patients in ANY WAY. I'll try to comply, so I may be even more boring than usual this month.

4) I got new glasses today. They're very cute, kind of "cat's-eye", in a tortoise-shell color that is very "sexy secretary", to quote Stacy & Clinton. I keep spotting myself in the mirror and going "Damn, who is that???" It's going to take some time to get used to.

5) The kitty continues to grow by leaps and bounds, as my husband reports to me. His new favorite game is to climb our furniture and paw at things until they fall onto the floor. This includes remote controls, Wii controllers, and glasses of water. What a fun game!

6) Once again, I find myself preparing to make baby blankets for 3 babies at once. Yes, my stepsister and stepbrother's wife are pregnant at the same time AGAIN and due within weeks of each other. In addition, a friend of mine and her husband are expecting their first child at around the same time as the other two. I've bought a huge stack of baby yarn, which incidentally was hard to explain to my mother-in-law when she was in town a few weeks ago.

As someone who finds psychological illness fascinating, here is an excellent blog post by someone "coming out" with borderline personality disorder. This writer has amazing insight into a disorder where patients usually do not have any, but in a way this makes him suffer more because he sees the things he does, the defense mechanisms, the fits of rage, etc. I could compare it to "Girl, Interrupted," but even though they involve the same disorder, they are quite different. Enjoy!: The Shape of Days.

About Me

This is the disclaimer for this blog. I live in Nowheresville, USA, and I'm not actually a young female doctor, but an old hairy guy living in a trailer typing on a Commodore about my fantasies of always wanting to be a doctor. Everything on here is patently false and should not ever be construed as truth. I made it all up. Also, I'm not YOUR doctor, so if you got here by Googling "how to treat toenail cancer" you need to go visit YOUR doctor. These are my opinions, not medical advice.